Healthcare Commission - research

The Healthcare Commission has looked at the results of the NHS staff survey and the patient survey for NHS acute trusts in England to see if there is an association. The aims of this analysis were to maximise the potential of the survey data and to explore the relationship between feedback from staff and patients. The following page includes details of the analysis methods used, the results and overall patterns.

Background

The annual NHS staff and patient experience surveys cover all NHS trusts in England and are coordinated by the Healthcare Commission. They are among the largest such surveys internationally and aim to feedback to trusts to identify areas for improvement. The results are also used in the Healthcare Commission's assessments of trusts and to monitor the Department of Health's PSA target with Treasury regarding improvements in patient experience. The surveys also offer a unique opportunity for adding to the national and international evidence base.

Policy context

• It is one of the five priorities in the NHS Operating Framework 2008/09:
  • improving patient experience, staff satisfaction and engagement.
• The NHS Next Stage Review focuses on:
  • safe, personalised, clinically effective care
  • locally driven
  • empowerment of frontline staff to lead quality improvement
  • valuing the work of NHS staff
  • pledges to staff.
• · The relationship between staff and patient experience is critical, but there is limited evidence available on this.

The data

• 2006 surveys of staff and inpatients in 166 acute and specialist trusts in England
• inpatient survey: 81,000 respondents, response rate 59 per cent
• staff survey: 69,500 respondents, response rate 52 per cent

Methods of analysis

• Inpatient survey
  • responses scored on a scale of 0-100 (poor-good)
  • scores adjusted for age, gender, admission method
  • 13 questions selected, relating to: respect & dignity, staff-patient interaction, cleanliness, overall rating
• Staff survey
  • analysis restricted to 'frontline' staff (65 per cent of all staff)
  • scores adjusted for occupational groups
  • 28 staff survey items: 18 questions, 10 multi-item
• all analyses at trust level
• two sets of analyses:
  - correlation analysis to test associations within the staff survey
  - regression analysis to test associations between surveys
• 17 multiple linear regression models run, with:
  - patient survey scores for each question as the "outcome' variable
  - staff survey scores for 28 items as the 'explanatory variables, to see which items emerged as significant
• analyses adjusted for:
  - London Vs non-London trust
  - trust type (general acute, teaching, specialist)

Staff survey items

Correlations within the staff survey

There were several strong correlations, examples of negative and positive associations:

• well-structured appraisals:
  • positive association -markers of good working environment, managerial support, job satisfaction
  • negative association- work pressure, intention to leave
• work-related stress:
  • positive association -harassment from patients/colleagues, work pressure
  • negative association -markers of good working environment
• intention to leave:
  • positive association - stress, work pressure
  • negative association - work-life balance, managerial support, organisational climate, incident reporting, action on harassment

Results

Respect and dignity

Staff-patient interaction

Information

Cleanliness

Patients' overall rating

Overall patterns

• Most associations went in the 'expected' direction, for example, positive staff experience equals positive patient experience
• Staff factors appearing frequently: availability of hand washing materials, witnessing/reporting errors, managerial support.........health and safety training, stress, working hours
• Most striking was availability of hand washing materials
• These factors could be proxies for underlying factors
• National Patient Safety Agency (NPSA): higher error reporting indicative of safety culture
• Working conditions and staff morale appear to impact on
  patient experience (other research corroborates this)
• Other effects: London/non-London, trust type

Provisional results for 2007 surveys

• broadly similar findings
• staff factors appearing most frequently:
  • positively associated with patient experience:
    availability of hand washing materials
    health and safety training
  • negatively associated with patient experience:
    working extra hours
    flexible working options
    intention to leave

Caveats

• there was no specific hypothesis to test, therefore a stepwise regression was used to maximise 'goodness of fit'
• there were strong correlations within staff survey item scores
• some predictive variables on staff side may have been displaced by others
  • hence the need to consider staff factors in the round
• cannot demonstrate causality
• hypothesis that staff factors impact on patient experience, but causality could operate in the reverse direction
• other factors at work also, as analyses explain up to 59 per cent of inter-trust variation in patient experience

Implications

• Workforce issues central to safe, high quality services
• Potential for improving the quality, safety of services and patient experience
• Trusts should monitor and act on their staff survey results
• There are implications of workforce issues for commissioners
• Data constraints in repeating the analysis for other sectors (but no reason why similar relationships would not apply)
• The Healthcare Commission report 'Learning from Investigations' highlighted the need for:
  • systematic use of information by trust boards etc
  • managers to elicit views re safety from frontline staff